Transparency a problem for NHS IT

And suppliers still in the dark after five years

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If there was one lesson that should be drawn from the controversial National Programme for IT and applied to other projects it would be a need for transparency, according to the National Audit Office (NAO), which published its enquiry into the £12.4bn NHS modernisation programme on Friday.

NAO assistant auditor general Anna Simons said: "The key lesson is how we engage the staff - how to get them on side."

"Transparency" is what is needed, she said, though the NAO report uses the less loaded term, "clarity".

The first recommendation of the report is that Connecting for Health "should provide greater clarity to organisations and staff in the NHS".

Right on cue, on the day the NAO report was published, but arguably three years late, health minister Lord Warner admitted he had started telling NHS staff, "we all need to work together".

"We should have worked harder at the beginning at staff engagement," he said.

This is not news for the programme, however. Secrecy has been a deliberate ploy designed to get the system railroaded against all the known principles of good systems engineering.

The roots of troublesome IT systems are usually stuffed precariously in shallow soil because of a lack of transparency and consultation - not just with users and administrators, but suppliers as well. This is because computer systems are one element of a programme of organisational change. Change requires the co-operation of the plebs, who are only too willing if they are not treated like plebs; and an open relationship with the designers for obvious reasons.

Yet Connecting for Health is still trying to justify its secrecy, even as it admits it was wrong. "If you tell people too much too early, they get their hopes up," said Professor Mike Pringle, a clinical wonk for Connecting for Health.

But the programme has broken its promise to open to scrutiny before. IT suppliers were told in 2003, after two years of living in the dark, that the programme was ready to include them. This was important not only because their livelihoods were threatened by the programme, but because they knew more than anyone else what there was to know about NHS IT. The programme told suppliers it recognised this and had learned to value transparency.

This spring, however, suppliers were being given the same reassurances again, after another three years pulling their hair out without a clue what was going on. They are as hopeful that things have changed now as they were in 2003, which is naively so.

Looking back, suppliers think the programme directors had no idea what was going on either. They where making it up on the hoof. Not the best way to run a multi-billion pound IT project. But there was a political timetable to meet and political reputations to maintain.

There are a few suppliers who have been let into the programme's inner sanctum, but they are contractually bound to the utmost secrecy. So they all toe the party line.

Suppliers consequently survive on a diet of "misinformation and gossip" they can scrape from between whatever official line they are told, said one prominent health IT provider. Suppliers can't talk openly about the programme for fear of having their livelihoods taken away, so there is no healthy debate.

"Suppliers try to help themselves by sharing information. In the absence of formal information that's all we can do," said the source.

There are those who argue for public scrutiny as well, and not just opposition politicians. Last month's Accounting, Auditing and Accountability Journal published a paper that described how the Australians came to ban secrecy from public projects because they discovered it encouraged waste, inefficiency, mistakes and corruption.

As expected, the NAO has found that the NHS project, late and over budget as it is, has proved a lesson in how not to run an IT project. Yet it only considered this key failing from the perspective of the users. Granted consultation with the users is more likely to "increases the likelihood of a successful implementation", but so is wider transparency.

That does not bode well for another risky project, ID cards, which has secrecy written into its parliamentary bill. ®